Clinical Consult

Healthy, active 15 yr. old female athlete with 6 month history of L sided anterior chest wall pain onset after some intensive training for track and cross country running.  She was worked up for all possible cardiac conditions and had an X-Ray of her chest and sternum which were clear.  She has a constant 1 to 2/10 pain along the L sternocostal joints of the 2nd through 5th ribs with palpable tenderness but no edema (rule out Tietze syndrome).  Her pain is aggravated by running and she can continue running despite her pain, but after 3 to 4 miles she feels she has to stop because the pain becomes unbearable.  Interestingly, her pain is not aggravated by deep breath inspiration, coughing or high intensity cardiovascular workout on an exercise bike.  She can also rollerblade without pain.

My differential diagnosis has been costochondritis affecting the left 2nd through 5th sternocostal joints, and the focus has been on activity modification to allow the condition to heal itself.  The problem has been that she is an extremely competitive athlete and her track coach is pushing her to continue her running and training in order to remain competitive for herself and the team.  Her main goal is to enter the Naval Academy and she is worried that she may not be accepted or even considered for application if she has any history of chest pain with exertion.  Any thoughts?

Louie Puentedura, PT, DPT, OCS, FAAOMPT

Comments

[Damien Howell MS, PT, OCS]

I would suggest you look at her run, to determine if there is asymmetrical arm swing and trunk rotation. This is best done with slow motion video analysis of running motion. Asymmetrical arm and trunk rotation can be related to compensating for a previous injury in the lower extremity, and if so this previous limitation or weakness needs to be addressed. Asymmetrical arm and trunk rotation can be related to asymmetrical running, that is, excessive amounts of running counterclockwise on a short track.

Damien

[Dan Pinto]

I have seen ribs taped for support because a fracture continued to provide a young woman with pain during activity. I suggest taping the ribs before a run to see if it provides any benefit. I recognize that taping over the 2-5th ribs may be difficult, especially in a 15yo female. Obviously you don't want the ribs to be restricted to move for prolonged periods of time so you would want to use the tape for the agravating activity only.

[Ann]

I wonder if her pain may be due to inadequate support of breast tissue and/or fascial inflammation from an impact activity like running. Breast tissue suspension would seem to correlate with her pain location.

[Erica Meloe]

Have you done a mechanical evaluation of the thoracic spine and the ribs? Even if she does not have pain with inpsiration or exhalation, she could possibly have a restriction there or even a structural rib dysfunction. How much arm swing does she have with running?
Erica

[Louie Puentedura]

Thanks for your comments so far everyone.

Erica - I did complete a mechanical evaluation of the T spine and ribs and found no problems. I was thinking she may have had some joint restrictions there at her L T2 through T5 costotransverse or costovertebral joints and even tried a couple of joint mobs one time - no change - and a supine PA thrust - again, no change. I think we can pretty much rule a thoracic spine problem out and concentrate more on sternocostals.

Dan and Ann - I did consider the possibility of breast tissue issues and with her mother present, we discussed her wearing a tighter sports bra (maybe a size smaller) but when she tried it out, it didn't make any difference. We didn't consider strapping or taping the area. I'd be a little concerned about skin irritation, and to be honest, I've never strapped breasts before and would probably have to make it up as I go along. Not a good idea :(

Damien - We did discuss her running style and she has a track coach who is ever vigilant about the "correct" arm swing action. What she did notice was that as she ran further and got into her pain, she would find herself limiting her arm swing more in an attempt to brace herself and decrease the pain - but it was never successful and she would have to stop running. The interesting thing here is that she can rollerblade and pump her arms for faster speeds and it doesn't aggravate her pain at all. She can get a terrific cardiovascular workout on the rollerblades or on an exercise bike/ regular bike and she wont aggravate her pain.

I'm thinking its costochondritis and will just need rest from the aggravating activity and time. Am I missing something?

[Tim Flynn, PT, PhD]

It appears that the only clinical aggravating factor you can use for test-retest within session change is tenderness to palpation. This makes it difficult to assess response to treatment and narrow down the contributing factor if it is indeed musculoskeletal in nature. I would manually treat the lower thoracic, lumbar spine and hips. Look for impairments in symmetry right to left and move it, recheck tenderness, and move on to the next area. I would particulary look for the left or right pelvic region being elevated (ischial tuberosity prone) with tension of the lumbar PVM. My sense would be that since she appears fine with aggressive aerobic exercise that is not high impact in nature, that the problem is coming from distal to her area of complaints.

[Damien Howell MS, PT, OCS]

If you can watch her as she runs on a treadmill. Look for asymmetrical arm swing when she is running without pain, early in the run. Because her symptoms are on the left side of the chest if there is asymmetrical arm swing I would expect the left elbow comes father back than the right. If the left elbow comes farther back it is likely there is exaggerated left trunk rotation. I would expect you might find a short and/or stiffer right hamstring and perhaps a shorter step length on the right at foot strike.

I suspect running requires a greater degree of hamstring lengthening at foot strike than what is required at roller blade strike.

Obviously if the right hamstring is shorter and/or stiffer treatment intervention should address this impairment.

If the right hamstring is shorter and/or stiffer it raises the question why is there this symmetry occurred. Does she roller blade around a oval in counter clockwise direction, which is likely to involve a greater degree of left trunk rotation?

Damien

[Carina Lowry]

Louie,

I'm afraid I agree with Tim in that the problem may be lower than the T2-T5. Have you check TL junction/SIJ? I would maybe start at the feet looking at pronation/supination and work up, ie hamstring length, pelvic obliquity, etc.

I know this is a very biomechanical approach (which I try to avoid) however unless she is very mammiferous, it is more than likely coming from the LE/pelvic biomechanics when she runs, and she may benefit from some core/pelvic stabilization.

Good luck,

Carina

[John Ware]

Carina,
Why do you avoid a biomechanical approach? All of the suggestions I've read on this thread are well-reasoned, and are essentially biomechanical analyses. Louie may very well come up with some ideas to help hasten this young woman's recovery, which could have long-term impact on her career and life. Why has "biomechanical" become a pejorative to some on this blog? The human body is an exquisite, complicated machine, after all. Just because we don't always have adequate theories and explanations for how it works, doesn't mean we should quit trying-or avoid a tried and tested approach.
John

[Carina Lowry]

John,

I am not saying that a biomechanical approach is contumelious, and I certainly do not look upon it as vituperative. I think much of our literature at one point in time was a revelation based upon a biomechanical model then subject to the rigors of research. However I also do not think we need to perpetuate an archaic system by over thinking things....

I agree with this case to return to the basic biomechanics might lead to a revelation.

Carina

[John Ware]

Carina,
I just put down my dictionary, and I'm still not sure why you avoid using a biomechanical approach-in lieu of what approach? I agree that there has been some "over-thinking" that falls under a biomechanical paradigm (e.g. much of the osteopathic approach (FRS,ERS, etc), SIJ motion and position assessment (torsions, standing flexion test, Deerfield test, etc.), but I don't think that that means the biomechanical paradigm is fundamentally flawed-nor would I refer to it as archaic, which is pejorative, in my view. Actually, biomechanics is a young science in the grand scheme of things.
I'm certainly no expert in the field, but I've read enough of the biomechical literature to have a tremendous amount of respect and appreciation for the contributions made by these researchers to the field of physical therapy. Perhaps as a profession, we need to look at why some "biomechanical" explanations are incomplete or just downright wrong, and, more importantly, why are they still being taught in PT schools, residencies and continuing education courses. I'm going to pick on Ola Grimsby because I know he can take it. He has proposed an exquisite biomechanical explanation for the presence of the change in leg length during supine to long sitting in pt's with SIJ dysfunction. The problem is that the test has no test-retest or inter-rater reliability. I was taught the test in residency and have tried to incorporate that test along with the other tests included in the Cibulka cluster in practice. They have added little utility or insight into the treatment of the vast majority of of my pt's with lower quarter dysfunction. I have dispensed with SIF motion assessment tests for the most part. The evidence shows, to this point, that the provocation tests for SIJD are more reliable and valid. My friend Dave Z. refers to these tests as "checking the angle of the dangle," which pretty much sums it up. I think there's a whole host of reasons why we cling to some of these examination techniques, including guruism, flawed research, flawed education, even greed. But I don't think we should throw out the baby with the bath water. This quote from an earlier quote of the week on this blog sums it up:
“Because science carries us toward an understanding of how the world is, rather than how we wish it to be, its findings may not in all cases be immediately comprehensible or satisfying. It may take a little work to restructure our mindsets. Some of science is very simple. When it gets complicated, that’s usually because the world is complicated - or because we’re complicated. When we shy away from it because it seems too difficult (or because we’ve been taught so poorly), we surrender the ability to take charge of our future.”
Carl Sagan, in his book The Demon-Haunted World: Science as a Candle in the Dark.
John

[Carina Lowry]

John,

I suppose that first we must determine that we both agree that you can actually move the SIJ. I know there are very respected individuals out there that do not believe that you can move the SIJ.

That being said, I avoid the biomechanical model for several reasons:

1. The reliability and validity of individual motion tests are poor at best for the spine and SIJ (Laslett, Spine 1994;19:1243-1249). However the ability to determine hypomobility or hypermobility of the spine with p/a glide has good reliability, and when a patient has hypomobility determined by p/a glides and a manip technique is applied, the NNT is 2.1. When the patient has determined hypermobility by p/a glide and is put on a stabilization program, the NNT is 1.6 (Fritz, APMR, 2005;86:1745-52.

2. Clusters of SIJ tests have better reliability than individual tests(Cibulka JOSPT 1999;29(2):83-92. The cluster of 4 tests gave a Sn of .82 and Sp of .88--which is really pretty good. Yet, how did Cibulka choose these tests? Experience? This then leads us to the question of does the patient have a posterior torsion on the right or an anterior torsion on the left or maybe he has a backward rotated sacrum with a downslip that looks similar to a posterior torsion and he has abnormal landmarks for the ASIS's. I hope you get my point that the tests are ultimately based upon palpation, which although I consider myself to have fairly good palpation skills, it is just not worth it because the reliability of palpation is poor.

3. Do we really KNOW FOR SURE that our manual techniques are only targeting the specific vertebrae or SIJ we are aiming to effect? I would argue no--the "SIJ slam" also affects the TL junction and the entire lumbar spine. In the manipulation studies that used the general SIJ manip--which many are calling "lumbopelvic manip" due to the inability to pinpoint it specifically to the SIJ--the technique was done twice on the painful side and then up to two times on the opposite side if there was no cavitation felt or heard. (Flynn, Spine 2002;27(24):2835-2843. Childs, Ann Int Med. 2004;141:920-928. Whitman JOSPT 2004;34:662-675.

What do I use instead of the biomechanical approach? I use clinical outcomes to determine if the technique I did had an effect. Even the NPRS has an MCID of 2 points in a LBP population (Childs, Spine 2005;30(11)1331-1334. I think palpation test-retest has poor reliability at best, and honestly only measures one aspect of movement. It doesn't take into account the muscle action across the joint or the psychological beliefs of the patient. So yes, I have freed myself (for the most part) from the biomechanical OMT approach. I am not saying there isn't a place for it, and sometimes I will go back and try to figure out if the upslip and posterior torsion was corrected....but then again was it because I affected the joint that needed it or did my thrust technique actually affect the other joint (Cibulka, Phys Ther. 1988;68:1359-63).

And although some people would disagree, I am much more sane now that I am not trying to figure out which way the sacrum is "tilted". This whole OMT approach to pain (ie torsions, ERS, FRS, etc) is very similar to subluxations that have never been shown to exist on radiographs but a profession has become built around the idea....

I think instead of focusing on the biomechanics of one individual joint, we should look at the entire LE from the ground up and determine joint mobility, muscle flexibility and strength, and how one joint is causing the distal or proximal joint to have poor biomechanics. To me that is the TRUE meaning of biomechanics.

Thoughts?

Carina

[John Ware]

Carina,
The SIJ moves-end of story. How much? and Is it clinically relevant or manually palpable? is a whole nother story.
But now I think we're getting somewhere. You placed the modifier "OMT" behind your definition of biomechanical. There's not a single citation you reference, with the exception of the Cibulka study, that I take issue with, and, as my last post intimates, the days of FRS and ERS are moribund. And, in my opinion, thankfully so. I was tired of sitting in the back of the class wondering how to check for "the angle of the dangle" (to steel a phrase from Dave Z). As far as the Cibulka cluster for SIJD goes, we know now that the "gold standard" to determine the validity of those tests was SIJ injection, which itself has been shown to be unreliable in identifying the SIJ as the source of symptoms (Joint Bone Spine. 2006 Jan;73(1):17-23.
Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable
for diagnosing sacroiliac joint pain.
Berthelot JM, Labat JJ, Le Goff B, Gouin F, Maugars Y.)
Therefore, those validity data you site are probably as useless as those tests have been to me over the last 8 years in the clinic. (I was blissfully ignorant the first 4 years.)
However, we as manual PT's tend to look for evidence that not only helps our pt's, but also justifies what we do. What is lacking from your citations is the non-OMT biomechanically-based research. While we OMT's have been arguing amongst ourselves, Shirley Sahrmann, Linda Van Dillon and Barbara Norton have been plodding along over there at Washington University putting out some of the highest quality outcomes research, including RCTs, demonstrating the reliability and validity of movement balance theory for treating low back pain. Interestingly, I don't see that research referenced on this blog very often, if at all. Sometimes I think we OMTs are afraid that if Shirley's right, we must all be wrong. Then, we become a bunch of overqualified massage therapists, right? In fact, I doubt Shirley, who is as humble as she is brilliant, would claim her theory tells the whole story of movement-related pain syndromes in human beings. And if you make it to the AAOMPT conference in Charlotte next month, you may hear her say something to that effect. For my part, I'd absolutely relish observing her examine this 15 year old with chest wall pain. Wouldn't that be scary if Shirley was able to fix her problem without even touching her?
Ever fearless,
John

[Peter Szymanski]

Sorry, I've gotten way behind, and got into this thread so late. If anybody's still interested and wants to get back to the patient Louie asked about in the first place: Myofascial trigger points in the pec major can refer pain to the sternal costal area. See Travel & Simons Vol. 1. If there are active TrP, some manual release and stretching may be helpful. There is often a relationship with rib and thoracic dysfunctions. I agree also with analyzing her gait, her arm swing may be a contributing factor. Not to mention whats going on below. She may also have weakness/inhibition of her scapular atabilizers contributing. I'd be interested to know what her coach considers the "correct" arm swing pattern, it could be that she's trying to change something that doesn't need to be changed, or she's not ready for.

[Sean]

John,
Regarding the SI joint issues you've referred to, I've found that the joint itself produces very little pain.. What seems to be the main cause of pain is the resultant muscle guarding of the many contractile structures attached to the femur. In response to your comment about Sacral tilting, etc., I haven't found any reliable way of evaluating for such an issue.
As far as test/retest reliability I use a pt/PT gait analysis. They walk before and after each test and I watch them while they evaluate symptom changes. I find that about 10% actually need mobilized and m. energy techniques are effective and easily reproducible at home.
When an ilium is rotated it's pretty obvious just by looking at the patient in standing and supine. It's also easy to tell which direction it is in. But mobilization is usually unnecessary as self-stretches (gentle) and abdominal training, progressed to CKC LE strengthening will usually provide a graded improvement over the 2-3 months following initial eval. My theory is that it takes so long due to ligament laxity being resolved. Any thoughts?

[John Ware]

Sean,
I think the whole issue of rotated innominates is a red herring- at least it is in the vast majority of pt's with lower quarter m/s pain. There are so many muscular and capsular issues at play that can affect the apparent position of the lower limb. One of the most obvious, and in my experience, least appreciated, is the effect of the length of the lateral (and medial) thigh soft tissues. A lot of leg length inequalities and rotated sacrums have been misdiagnosed as such when it is simply an adaptive-or mal-adaptive- change in the length of the hip musculature. Why are we so willing to accept that a joint as solidly reinforced as the SIJ can twist and turn so readily? I've never understood this. As my inlaws in east Tennessee are wont to say, "It just ain't that complicated."

I suppose, then, what you mean by the SI joint producing "very little pain" is that it's not often a pain generator. If so, I heartily agree. I don't think, though, thatligament laxity of the SIJ is the culprit; rather, it is likely other strained soft tissues around the hip that are producing the symptoms. Your intervention as described is likely addressing the (brace yourselves OMPT's) muscular imbalances around the hip. Of the musculoskeletal soft tissues, is not muscle tissue the most readily adaptable to change?
John

[Sean]

John,
We agree on the muscles being the main cause of pain. However strained muscles elsewhere in the body do not respond anywhere near as well as these do to the proper torsional forces and/or stretching. Based on the reduction of apparent leg length discrepancy, improved gait, reduction of pain, and average 2-3 month recovery period, ligametus laxity is the only explanation I can come up with. If the medial and lateral muscle length were causing the leg length discrepancy independent of a pelvic rotation, wouldn't they either have to be bending the femur, or partially dislocating the femoral head from the acetabulum?
I am posting not to create an argument, but to better understand why what I do works so well. Maybe a pelvic rotation isn't the true cause, maybe the ligaments aren't overstretched, I don't have MRI, CT, or X-ray vision.
It's just that the explanation of muscles being strained seems to be only about half of the picture. As of now, for me the ends are justifying the means. But as a practitioner I'm trying to get away from that line of thinking. That's why I'm here.

[John Ware]

Sean,
Sorry for the long delay in responding.
In fact, I do believe that a significant change in the position of the femoral head in the acetabulum is often occuring in many lower quarter syndromes. I wouldn't call it a "dislocation," though. Rather, looking at the geometry of the hip joint, isn't it possible that the spherical femoral head could become mal-positioned in the acetabulum as the result of months or years of faulty lower quarter mechanics? Remember that a large portion of the anterior femoral head articular surface is not even in the acetabulum during normal standing and much of the stance phase of walking. The hip relies, therefore, on particularly strong ligamentous support anteriorly. I believe that it is the slow breakdown of this ligamentous support anteriorly, and to some extent superiorly, that allows for this malpositioning and thus an apparent leg length inequality. Certainly, the pelvis may appear rotated due to the resulting pelvic obliquity. I doubt, however, that in the vast majority of the cases that there is significant independent motion of the two halves of the pelvis. It just makes more sense to me that the hip joint is the weak link-at least it is relative to the SIJ.
Try this quick test with your next lower quarter/hip patient, who presents with an apparent LLI. After you've established in standing that one leg appears longer than the other, have the patient stand with her hips abducted (feet about 2 feet apart), then recheck the pelvic landmarks. If the iliac crests and PSIS's are now level, then you've established that there is a difference in soft tissue length of the lateral and medial hip musculature, have you not? I see this phenomenon frequently in the clinic. I have all but abandoned using the SI alignment tests as described by Cibulka as I have found them to be unreliable and unuseful.
As a side note: Notice the upsurge in hip joint arthroscopy over the last few years? The surgeons are calling it femoroacetabular impingement(FAI). Of course, it could well become the next fad in orthopedic surgery, and everyone will be getting their hip scoped. If we PT's get on the ball, though, we could help prevent a lot of needless-and expensive- surgeries.
John

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